Community Premier Silver 004 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,000 per person $6,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 40% coinsurance |
| Ambulance | $50 copay |
| Hospital stay (facility) | 40% coinsurance |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | 40% coinsurance |
| Outpatient procedure (physician) | 40% coinsurance |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | Share |
| Brand | $50 copay |
| Non-preferred Brand | $85 copay |
| Specialty | 30% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay |
| Imaging (CT/PET/MRI) | 40% coinsurance |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | This is the amount you’re responsible for when receiving services provided by a physician, surgeon, or other specialist. |
| Psychiatric hospital stay | 40% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.communityhealthchoice.org/wp-content/uploads/2023/06/27248TX0010004-05-2024.pdf |
| Drug and medication plan formulary | https://www.communityhealthchoice.org/wp-content/uploads/2023/04/formulary-premier-2024.pdf |
| Search doctor list | https://providersearch.communityhealthchoice.org/ |
